HHS RESHAPING THE HEALTH OF MINORITY COMMUNITIES AND UNDERSERVED POPULATIONS

Overview: Life expectancy and overall health has improved in recent years for a large number of Americans, thanks in part to an increased focus on preventive medicine and dynamic new advances in medical technology. However, not all Americans are benefiting equally. For too many racial and ethnic minorities in our country, good health is elusive, since appropriate health care is often associated with an individual's economic status, race and gender. While Americans as a group are healthier and living longer, the nation's health status will never be as good as it can be as long as there are segments of the population with poor health status.

The Clinton Administration has developed and implemented a number of strategies to improve the health of minority populations and help close these unacceptable health gaps. These strategies include a coordinated effort to eliminate racial and ethnic health gaps in six areas by the year 2010, enhanced resources for fighting HIV/AIDS in racial and ethnic minority communities, and the formation of a number of special work groups to review health status, determine research needs, and develop strategies that help improve minority health. The elimination of health disparities will require a national effort - public and private sector, individuals, and communities. A better understanding of the relationships between health status and different racial and ethnic minority backgrounds will also require working more closely with communities to identify culturally-competent implementation strategies.

The Department of Health and Human Services (HHS) plays a leading role in these initiatives. In 1999, the Centers for Disease Control and Prevention (CDC) made its first REACH 2010 grants to community coalitions in 18 states to help address racial and ethnic disparities in six key areas of health: infant mortality, diabetes, cardiovascular disease, cancer screening and management, HIV/AIDS and childhood and adult immunization. Since 1999, a total of 46 community coalitions have received REACH 2010 funding.

In November 2000, President Clinton signed legislation creating a new National Center on Minority Health and Health Disparities at the National Institutes of Health (NIH) for research among its institutes and centers that addresses racial and ethnic health disparities. The center will also support the training of researchers and provide educational loan relief for health professionals who commit to perform related research. The center promises to help all Americans who bear the burden of health disparities regardless of their race, ethnicity, gender, socioeconomic status or geographic location. It will expand and extend HHS' extensive, ongoing efforts to raise the health status of various groups, especially with regard to six specific areas - infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection and AIDS, and child and adult immunizations.

Highlights of the Fiscal Year 2001 Budget

For fiscal year 2001, HHS's budget includes $5.5 billion in funding for activities that directly target improving the health of minorities, a net increase of $720 million. President Clinton also signed legislation to establish the National Center on Minority Health and Health Disparities within the NIH. The center will help develop an integrated research agenda aimed at addressing the current and emerging health needs of racial and ethnic minorities and other populations with health disparities. The center will also support research training and other programs, including the dissemination of information with respect to minority health conditions and the disparate health status of other groups. The goal is to promote a robust environment for minority health disparities research with sustained funding for a wide range of studies, including basic, clinical and behavioral research, as well as research into the societal, cultural and environmental dimensions of health and the processes by which health is maintained or improved. The fiscal year 2001 budget includes a total of $130.2 million to support the new center.

Other highlights:

• Racial disparities. The budget includes $38 million to support community-based research and demonstration projects that focus on eliminating health disparities among racial and ethnic minority populations. This would continue the work begun by President Clinton, Secretary Shalala and Surgeon General David Satcher two years ago to eliminate racial and ethnic health disparities in six areas by 2010: infant mortality, diabetes, cardiovascular disease, cancer screening and management, HIV/AIDS infection rates and adult and childhood immunization.
  
  
• Improving Care for Native Americans. In fiscal year 2001, HHS received an additional $214 million, or 9 percent increase, from Congress to boost the budget of the Indian Health Services (IHS) to $2.6 billion. Adding estimated health insurance collections of $414 million, $100 million in mandatory diabetes funds, and $5 million for living quarters funding, results in $3.2 billion in IHS program-level spending. This increase means more comprehensive clinical and environmental health activities, stronger injury prevention programs, increased mental health and more opportunities for Native Americans to visit doctors and dentists. Tribes will control approximately 44 percent of the IHS budget.

The department's fiscal year 2001 budget also includes:

• $94 million for health professions diversity training through the Health Resources and Services Administration (HRSA);
• $4.7 million for nursing workforce diversity, also through HRSA; and
• $1.6 billion for minority health research at the NIH.

HHS Initiative to Eliminate Racial and Ethnic Disparities in Health. The department is in the third year of its signature effort to address minority health through the President's plan to eliminate racial and ethnic disparities in six key areas of health by the year 2010: infant mortality, diabetes, cardiovascular disease, cancer screening and management, HIV/AIDS, and child and adult immunizations. Also, CDC has launched the Racial and Ethnic Approaches to Community Health (REACH 2010) demonstration project, which in fiscal year 2000 awarded approximately $27 million to community coalitions to help address racial and ethnic health disparities in the U.S. Since 1999, a total of 46 community coalitions have received REACH 2010 funding.

In November 2000, HHS' Agency for Healthcare Research and Quality (AHRQ) announced a major research initiative, known as Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED), to build greater knowledge about the factors underlying ethnic and racial inequities in health care and to identify practical tools and strategies to eliminate these disparities. The initiative, involves nine separate projects, each of which will include a series of studies. Funding for these projects will total an estimated $45 million over five years.

The Assistant Secretary for Health/Surgeon General and the Assistant Secretary for Planning and Evaluation are co-directing efforts in this area, including reviewing the status of the department's goals to eliminate health disparities, consulting with minority communities and the scientific and research communities, and reviewing and making recommendations about the department's resources and programs to attack racial and ethnic health disparities.

HHS has taken several steps to advance the racial and ethnic health disparities initiative, including:

• Publicized in March 2000 the first state-by-state look at risks for chronic diseases and injury for the five major racial and ethnic groups, which identifies wide disparities, even among members of the same racial and ethnic group living in different states;
  
  
• Sponsored a three-day conference on racial and ethnic health disparities research at NIH in April that drew more than 800 people from around the country to Washington, DC;
  
  
• Developed an informational World Wide Web site for the Initiative to be used by interested media and communities [http://www.raceandhealth.hhs.gov], and expanding the Web site of HHS' Office of Minority Health [http://www.omhrc.gov];
  
  
• Disseminated internal work group reports with recommendations on how to address the six health focus areas and data needs on the race and health Web site;
  
  
• Solicited public input about the racial and ethnic health disparities initiative from a series of regional and national meetings regarding Healthy People 2010, the national disease prevention and health promotion agenda for the year 2010;
  
  
• and reviewed departmental data collection systems and made recommendations on how to improve data collection for racial and ethnic minorities.

Already, HHS has made notable progress in the following six health areas that are goals of the department's Initiative to Eliminate Racial and Ethnic Disparities in Health:

• Diabetes. The prevalence of diabetes in African-Americans is approximately 70 percent higher than whites and the prevalence in Hispanics is nearly double that of whites.

In 1998, the IHS awarded 286 grants to Indian communities for programs focused on primary prevention of diabetes and promoting healthy lifestyle choices, including substance abuse prevention and treatment and mental health services. The programs will reach more than 100,000 American Indians and Alaska Natives suffering with diabetes as well as another 30,000-50,000 who are at risk or have undiagnosed cases. Comparing the 1994-96 Indian adjusted death rates with the overall U.S. population, the American Indian and Alaska Native population has a diabetes death rate that is 3.5 times greater than the overall population.

In addition, HRSA launched an intensive effort to help its community health centers prevent, diagnose and treat diabetes. The centers are the health care provider of choice for 10 million people, 65 percent of whom are racial and ethnic minorities.

Also, the Health Care Financing Administration (HCFA) announced in 1999 that the Medicare program would be taking steps to ensure that all patients with renal failure, regardless of race or ethnicity, are being evaluated for transplantation. The purpose is to ensure equal opportunity for transplantation as part of the patient's long-term care plan. Diabetes complications like renal failure and lower extremities amputations are more pronounced in some minority populations.

CDC has funded REACH 2010 projects involving diabetes to entities in Albuquerque, N.M.; Charlotte, N.C.; Cherokee, N.C.; Chicago; Detroit; Charleston, S.C.; Los Angeles; Lower Rio Grande, Texas; Seattle, Lawrence, Mass., New York, N.Y., Nashville, Tenn. and Oklahoma City, Okla.

• HIV/AIDS. While racial and ethnic groups account only for about 25 percent of the U.S. population, they account for more than 50 percent of all AIDS cases. While overall AIDS deaths are down dramatically, AIDS remains the leading killer of African-Americans age 25-44.

In response to the severe and ongoing problem of HIV/AIDS in racial and ethnic minority communities, HHS joined President Clinton and the Congressional Black Caucus in announcing a special package of initiatives on October 28, 1998. The comprehensive new initiative invested an unprecedented $166 million in fiscal year 1999 to improve the nation's effectiveness in preventing and treating HIV/AIDS in African-American, Hispanic and other minority communities. This initiative is addressing physical and mental health needs as well as issues related to substance abuse prevention and treatment.

On June 16, 1999, the Administration announced that Detroit, Philadelphia and Miami would be the first of 11 U.S. metropolitan areas to receive special technical assistance from federal Crisis Response Teams to help combat the spread of HIV/AIDS among racial and ethnic minority populations. The Crisis Response Teams will meet with local officials, public health personnel and community-based organizations and help them develop targeted strategies to curb the rapid spread of HIV/AIDS among minority populations in their communities.

Other components of the HIV/AIDS initiative for communities of color include:

• Funding for community-based organizations to provide new services, technical assistance and faith-based HIV prevention programs will be made available through CDC and Substance Abuse and Mental Health Services Administration (SAMHSA);
• Supplemental funding under HRSA's Ryan White CARE Act is expanding service for some of the hardest hit minority communities and establishing AIDS Education and Training Centers at Historically Black Colleges and Universities to provide ongoing AIDS education to health care providers serving African-American communities;
• Through SAMHSA, HHS is providing funding for comprehensive mental health and substance abuse prevention and treatment programs for African-Americans and Hispanics with HIV/AIDS or at-risk for it; for community-based outreach to minority populations at risk for HIV; and for expanding HIV/AIDS and substance abuse prevention and treatment options for minority populations; and
• Resources for increasing the number of African-American principal investigators conducting HIV/AIDS research, and broadened research on HIV/AIDS and minorities, including an increased emphasis on behavioral research linking substance abuse and HIV infection rates in African-Americans are being made available through NIH.
• The department received $357 million from Congress in fiscal year 2001 to continue these expanded activities to combat HIV/AIDS in minority communities. An $11 million grant program will also begin in May 2000 to support four five-year demonstration projects and one evaluation center to provide innovative health care and support services for people with HIV/AIDS living in the U.S.-Mexico border region. The grants will go to organizations in the border states of Arizona, California, New Mexico and Texas.
• CDC has awarded REACH 2010 grants for HIV/AIDS in Dorchester, Mass., and Miami.
  
  
• Infant Mortality. Mortality from Sudden Infant Death Syndrome (SIDS) continued to decline, and more Americans learned the importance of placing infants on their backs to sleep to prevent SIDS. Timely prenatal care also reached record levels in 1999 as an estimated 83.2 percent of women received care in their first trimester of pregnancy. The teen birth rate, associated with infant mortality and low birth weight, also fell three percent in 1999, continuing an eight-year trend. The birth rate for teenagers 15-17 years dropped six percent for 1999 to a record low of 28.7 per 1,000. From 1991-99, birth rates for teens 15-19 years dropped 20 percent, including a 30 percent drop for black teens.

Yet, there was no change in the preliminary infant mortality rate in 1998: the overall infant mortality rate was 7.2 infant deaths per 1,000 live births, the same as the record low reported in 1997. It is the first time there has been no improvement in this measure in nearly four decades, and the rate for African-American infants is still more than twice the rate for white and Hispanic infants (13.7 deaths per 1,000 births vs. 6 deaths per 1,000).

The National Institute of Child Health and Human Development (NICHD) has also broadened its efforts to reduce SIDS. As part of the "Back To Sleep" campaign that encourages parents and caregivers to place children to sleep to prevent SIDS, NICHD distributed packages of "Back To Sleep" educational materials to all licensed daycare centers in the U.S., including many centers that serve African-American and Hispanic communities.

In December, HRSA announced a new framework for the national Healthy Start Initiative to focus and energize its efforts to improve the health of high-risk moms and babies in areas with high rates of infant mortality. Based on the lessons learned during the six-year evaluation of the first 15 Healthy Start projects, the project's communities are now required to build strong linkages with statewide maternal and child health programs and offer a "core" set of proven interventions.

In conjunction with "SIDS Awareness Month," HHS in October 2000 unveiled a new resource kit for reducing the risk of SIDS in African American communities. The kit contains culturally appropriate materials such as fact sheets, brochures, and a leader's guide to encourage people to lead discussion groups in various community settings on ways to reduce the risk of SIDS. This is part of a new initiative to develop and implement a community-based approach to eliminate the disparity in SIDS rates impacting African-American babies. The new campaign is led by NICHD and will be carried out by a partnership with the National Black Child Development Institute, HRSA, the American Academy of Pediatrics, the SIDS Alliance and the Association of SIDS and Infant Mortality Programs.

CDC has awarded a REACH 2010 grants for infant mortality to entities in Flint, Mich.; Salt Lake City, Utah; Tallahassee, Fla.; and San Francisco.

• Immunizations. Immunization rates for the complete series of childhood immunizations have reached a record high of 80 percent, and levels for the most critical vaccines are nearly the same for children of all racial and ethnic groups - closing a gap that was as wide as 26 points a generation ago. But while 81 percent of white children have received the complete series by age two, only 74 percent of African-American children and 75 percent of Hispanic and American Indian and Alaska Native children are fully vaccinated.

In April 2000, Secretary Shalala announced a new Spanish-language childhood immunization public awareness campaign to create and distribute culturally relevant and language appropriate educational materials. The Spanish-language theme, "Vacunelo A Tiempe ... Todo el Tiempo," ("Vaccinate Your Children On Time, every Time"), encourages parents and caregivers to talk with their child's health care provider to make sure their child is up to date by age two. The Spanish-language PSA is narrated by popular Cuban-American musician Jon Secada.

In December 2000, the President directed the U.S. Department of Agriculture to assess the immunization status of the five million children under the age of five participating in the Women, Infants, and Children program and refer them to a healthcare provider when appropriate. The CDC will help develop a national strategic plan to ensure more accurate and cost-effective immunization assessment, referral, and follow-up for children at risk.

As for adults, 1998 data show that only 63 percent of the elderly received their annual flu shot during the preceding year, and only 46 percent ever received a pneumococcal vaccine. Significant progress is still needed among certain populations with substantially lower coverage, including African-American and Hispanic persons. Among persons aged 65 years or more, influenza and pneumonia were the fifth leading cause of death for African-Americans and Hispanics as well as non-Hispanic whites.

In an effort to increase immunization rates among older adults, the Clinton Administration launched an initiative providing Medicare coverage for flu shots for the elderly in 1993. The shots are free for those enrolled in Medicare Part B from physicians who accept Medicare payment as full payment. Medicare also covers vaccinations against pneumonia. An aggressive outreach strategy by HCFA to reach minority seniors about immunizations includes the mailing of some eight million postcards in four languages to Medicare beneficiaries as reminders, television and radio announcements in Spanish, and partnerships with Historically Black Colleges and Universities.

CDC is studying factors influencing the use of vaccines by African American physicians and using feedback and assessment from immunization providers to improve vaccination levels among older African American women. Gospel star CeCe Winans joined HHS' flu shot public education campaign in November 1999 by recording a 60-second radio segment encouraging African-American seniors to get their flu and pneumonia shots this winter. The spots were heard on the 300-station American Urban Radio Network in November, including on "The Bev Smith Show," which is also broadcast on the network.

CDC has awarded REACH 2010 grants for immunization to entities in Chicago; New York; Salt Lake City, Utah; and Torrance, Calif.

• Cancer Screening and Management. Many minority groups suffer disproportionately from cancer and disparities exist in both mortality and incidence rates. For men and women combined, African-Americans have a cancer death rate about 33 percent higher than that for whites (221.9 per 100,000 for African-Americans compared to 166.5 per 100,000 for whites). African-American women develop breast cancer less often than do white women, but they have a higher mortality rate, possibly due to later diagnosis and later entry into treatment. The death rate for lung cancer is about 23 percent higher for African-Americans than for whites (60.5 vs. 49.3 per 100,000). The prostate cancer mortality rate for African-American men is more than twice that of white men (54.1 vs. 23.3 per 100,000). Also, Vietnamese women in the U.S. have a cervical cancer incidence rate that is five times greater than white women, and African-American, Hispanic and American Indian women have higher cervical cancer death rates than the overall U.S.

In October 1998, Secretary Shalala announced new efforts to encourage mammography screening among special populations, especially to older, low income, and minority women, who tend to have the highest breast cancer mortality rates. HCFA and the National Cancer Institute (NCI) co-sponsored an education campaign about the new annual Medicare mammography benefit and the importance of regularly scheduled screening mammograms. In addition, HCFA offered mammogram screenings to older African-American and Hispanic-American women in Atlanta, Chicago, Cleveland, Los Angeles, Philadelphia, San Antonio, and Washington, D.C. HCFA is also working with NCI to develop and disseminate culturally appropriate breast cancer materials geared toward Asian American and Pacific Islander women.

CDC's National Breast and Cervical Cancer Early Detection Program offers free or low-cost mammography screening to uninsured, low-income, elderly, minority and Native American women throughout the country. New legislation enacted in 2000 with the President's support now allows states to provide uninsured women diagnosed with cancer through this CDC program with access to Medicaid insurance to cover critical treatment services. HCFA issued guidance to all 50 states in January 2001 explaining their option to provide the full Medicaid benefit. Funding for these screening services has risen from $72 million in fiscal year 1993 to $159 million in fiscal year 1999 and the program has gone from operating in just 18 states to all 50 states, the District of Columbia, six U.S. territories and 15 American Indian and Alaska Native organizations today. More than 2.2 million screening tests, including one million mammograms, have been conducted.

HHS is also addressing the cancer issue in minorities through its work to fight tobacco use, a key cause of lung cancer. CDC is funding 14 Prevention Research Centers to investigate explanations for differences in teen smoking rates among whites, African-Americans, Hispanics, Native Americans and Asian Americans and Pacific Islanders. The research project looks at such tobacco themes as reasons for smoking and not smoking; smoking images versus non-smoking images; youth messages; the social context of smoking; and an evaluation of communication strategies and policy approaches.

Also, through its Media Campaign Resource Center for Tobacco Control, CDC provides states and other organizations with top-quality broadcast, print and billboard messages for a variety of racial and ethnic minority groups: African-Americans, Hispanics, and a number of Asian American and Pacific Islander populations.

The federal battle against minority cancer got a boost on April 6 when NCI announced a $60 million program to address the unequal burden of cancer within certain special populations in the U.S. over the next five years. A total of 18 grants at 17 institutions will create or implement cancer control, prevention, research and training programs in minority and underserved populations. The cooperative relationships established by the networks will be used to foster cancer awareness activities, support minority enrollment in clinical trials, and encourage and promote the development of minority junior biomedical researchers.

CDC has awarded REACH 2010 grants for breast and cervical cancers to entities in Boston, Chicago, Newark, Birmingham and San Francisco.

• Cardiovascular Disease. Major disparities exist among population groups, with a disproportionate burden of death and disability from cardiovascular disease in minority and low-income populations. Compared with rates for whites, coronary heart disease mortality was 40 percent lower for Asian Americans but 40 percent higher for African-Americans in 1995.

In December 1998, HHS released a landmark study showing that total cholesterol levels for Americans decreased in men and women in several racial groups. However, the study showed that African-American adolescents experienced a smaller decline compared to non-Hispanic whites and Mexican Americans within the same age range. Of all the groups, African-American females continued to have the highest total cholesterol and experienced the smallest decrease over time. The finding of higher total cholesterol levels in African-American adolescents differs from the pattern in adults, in which blacks have lower total cholesterol than whites. This will be an area of continued research at NIH.

Among NIH programs designed to address heart health in minorities is a five-year-old pilot program in Washington, D.C. called "Salud para su Corazon" ("For the Health of Your Heart"), which works through the Latino community using Latino traditions to provide science-based health messages, educational materials and action strategies to improve heart health in Latinos. Because of the programs' success in chancing behaviors and increasing awareness, NIH's National Heart, Lung and Blood Institute is encouraging the use of this model in other Latino communities nationwide. This also will be a priority at NIH's new National Center on Minority Health and Health Disparities.

CDC has awarded REACH 2010 grants for cardiovascular disease to entities in El Paso, Texas, Charlotte, N.C., Chicago, Los Angeles, Detroit, Atlanta, Lawrence, Mass., New York, Lowell, Mass., Nashville, Washington, D.C. and Oklahoma City, Okla.

Eliminating Disparities Through Civil Rights Enforcement. Part of eliminating racial and ethnic disparities in health status involves meeting a civil rights challenge. As a result, the Office for Civil Rights (OCR) will continue to play an important role in the department's overall effort to eliminate these health disparities. OCR's activities involve investigation, outreach, and technical assistance designed to root out and prevent discrimination. OCR has been actively involved in building partnerships with relevant stakeholders in various cities in an effort to develop and implement a comprehensive plan for eliminating health disparities. OCR also is committed to addressing civil rights challenges confronting non-citizens and limited English proficient populations in the health context.

Addressing Departmental Initiatives on Minority Health. In December 2000, Secretary Shalala appointed 12 members of the new Advisory Committee on Minority Health, which will advise the Secretary on ways to improve the health of racial and ethnic minority populations, and on the development of goals and program activities within the Department. Committee members have expertise on issues including the unique challenges facing minorities in rural and urban communities, children, women, elders, and people with disabilities, mental illness, and AIDS. The committee will be chaired by Louis Stokes, former congressman from Ohio and former chair of the Congressional Black Caucus. The committee includes three members each from the Black/African American, American Indian and Alaska Native, Asian American and Pacific Islander, and Hispanic/Latino communities.

HHS also relies on a series of in-house committees representing a cross-section of agencies to look at health and customer service concerns that impact minority populations. These include:

Departmental Minority Initiatives Steering Committee. This broad, new committee has been designed to provide policy direction and guidance for key minority health initiatives: The Asian American and Pacific Islander Action Agenda, the Hispanic Agenda for Action, the Historically Black Colleges and Universities Initiative, and the Tribal Colleges and Universities Initiative. This steering committee is chaired by HHS Deputy Secretary Kevin Thurm and includes the Assistant Secretary for Health/Surgeon General, the Assistant Secretary for Management and Budget, and the heads or deputies of HHS divisions.

Departmental Minority Initiatives Coordinating Committee. This committee is comprised of senior agency staff who report directly to agency heads or their deputies. While the steering committee helps set department minority-related policy, this group helps draw together the actual work of all four minority initiatives to avoid duplication and foster interagency cooperation on strategies to improve the health status of minorities.

The following are the Minority Initiatives overseen by the Steering Committee and Coordinating Committee. These committees issue annual reports to identify the accomplishments of the minority initiatives, as well as areas for further development:

• Hispanic Agenda For Action (HAA) - Formed in spring of 1995, this initiative features a nine-point agenda for change, including the 1994 Executive Order on Educational Excellence for Hispanic Americans and strategies to enhance the department's ability to serve its Hispanic customers.
  
  
• Historically Black Colleges and Universities Initiative - Designed to strengthen the capacity of Historically Black Colleges and Universities to compete for and benefit from federal grants and participate in research.
  
  
• Tribal Colleges and Universities Initiative - Designed to ensure that tribal higher education institutions are not impeded from funding opportunities and from participating in federal health programs like other colleges and universities. In January 1999, the department sponsored a conference and exposition in Phoenix for tribal colleges and universities.
  
  
• Asian American/Pacific Islander (AAPI) Action Agenda - Launched by the department in 1997 to address health issues unique to AAPI. In June 1999, President Clinton issued an Executive Order creating a White House Initiative on Asian Americans and Pacific Islanders, pledging a partnership among federal agencies to address health and quality of life issues for AAPI throughout the United States, especially those living in underserved areas. The office that manages the government-wide White House initiative was housed within HHS.

Other Agency Projects:

• In February 2000, an important working conference, "Diversity and Communication in Health Care: Addressing Race, Ethnicity, Language, and Social Class in Health Care Disparities" was sponsored by HHS's Office of Minority Health and other governmental and non-governmental organizations. The purpose of the conference was to determine the state-of-the-art for improving provider-patient communication, to determine its adequacy to increase effectiveness of health care for racial and ethnic minorities and to develop a work plan to provide needed modifications. An action plan was generated at the meeting and will be disseminated to a broad audience including key departmental advisory groups and coordinating bodies. The plan is intended to serve as a basis of important policy initiatives.
  
  
• In December 2000, the HHS Office of Minority Health published a set of recommended national standards on culturally and linguistically appropriate services in health care. The 14 standards offer guidance to health care organizations on understanding and responding effectively to the cultural and linguistic needs brought by patients to their encounters with health care providers. They were developed with the aid of a national project advisory committee representing state and federal agencies, health care organizations and professionals, consumers, unions, and health care accrediting agencies, and received extensive public comments. The standards are offered as recommendations for adoption or adaptation by stakeholder organizations.
  
  
• In August 2000, HHS' Office of Civil Rights published a comprehensive policy on providing language assistance to health care and other critical programs for persons with limited English skills. The policy outlines the legal responsibilities of providers who receive federal financial assistance from HHS - including hospitals, HMOs and human service agencies - to assist persons with limited English proficiency.
  
  
• In October 2000, HHS co-chaired a "Call to the Nation to Eliminate Racial and Ethnic Disparities in Health," initiating collaborative efforts with the American Public Health Association and other organizations and leaders to focus national attention on the issues and activites being undertaken to end disparities in health status by the year 2010.
  
  
• In December 2000, Surgeon General Satcher and the American Medical Association signed a formal pledge to work together to eliminate health disparities and to improve the overall health of Americans by the end of the decade.

Since the initiative was launched in February 21, 1998, at least 17 states and the District of Columbia have begun to look very seriously at racial and ethnic health disparities.

• SAMHSA, in collaboration with HRSA and the Office of Minority Health, has produced a series of monographs that address issues related to cultural competence, which is the practice of being culturally aware and culturally relevant in delivering health and medical services to minority communities. Nine published or soon-to-be-published volumes address these issues from a variety of approaches, including guidelines for health professionals in community health settings dealing with various racial or ethnic communities on matters related to both general health care and substance abuse. HRSA has established an agency-wide steering committee to incorporate cultural competency into HRSA programs. SAMHSA also developed a four-page insert for six issues of the national Spanish language health magazine, Pro Salud, on mental health and substance abuse treatment and preventi on issues.

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